Hypertension in Pregnancy 2013 Update to ACOG Guidelines

Major Changes Simplified – four categories Pre-eclampsia/eclampsia Chronic hypertension (any cause) Chronic hypertension with superimposed pre-eclampsia Gestational hypertension Proteinuria no longer required for diagnosis Early delivery preferred – 37 0/7 wks Emphasis on postpartum pre-eclampsia

Pre-eclampsia Diagnosis BP criteria unchanged: Mild hypertension: 140-159/90-109 Severe hypertension: >160/>110 At least 2 determinations 4 hours apart Pre-eclampsia = hypertension plus EITHER Proteinuria: 24 hr >300mg OR pro/creat ratio >0.3 (>1+ dipstick nonpreferred) Thrombocytopenia: PLT <100K Impaired liver function: LFTs >2x nl New renal insufficiency: creatinine >1.1 OR doubled w/o other cause Pulmonary edema New-onset visual/cerebral disturbance

Severe Pre-eclampsia Diagnosis Pre-eclampsia plus Blood pressure >160 or >110 or Thrombocytopenia or Severe persistent RUQ pain Progressive renal insufficiency Pulmonary edema New-onset cerebral/visual disturbances NEW: Proteinuria does not predict severity NEW: IUGR does not predict severity

Management NEW: Timing of delivery: NEW: BP treatment Without severe features: 37 0/7 weeks Quality of evidence: moderate Strength of recommendation: qualified With severe features: depends on stability “only at facilities with adequate maternal and NICU resources” 34 0/7 weeks has strong recommendations for delivery decisions NEW: BP treatment Chronic HTN/pre-eclampsia: might not treat below 160/105 (low/qualified) Goal BP: 120-160/80-105 (low/qualified) Meds: labetalol, nifedipine or methyldopa (moderate/strong)

Management Postpartum: Gestational HTN, pre-eclampsia, chronic HTN with superimposed pre-eclampsia: Monitor BP in hospital or outpatient equivalent (moderate/qualified) 1st 72 hours Again 7-10 days postpartum If patient presents with new onset HTN plus headache or blurred vision, or with pre-eclampsia with severe HTN, admit, give Mg sulfate (low/qualified) Avoid NSAIDs for pain if HTN persists >24 hours